Never again? Challenges in transforming the health workforce landscape in post-Ebola West Africa

Abstract

Background The 2013–2014 West African Ebola outbreak highlighted how the world’s weakest health systems threaten global health security and heralded huge support for their recovery. All three Ebola-affected countries had large shortfalls and maldistribution in their health workforce before the crisis, which were made worse by the epidemic. This paper analyzes the investment plans in Liberia, Sierra Leone, and Guinea to strengthen their health workforces and assesses their potential contribution to the re-establishment and strengthening of their health systems. The analysis calculates the plans’ costs and compares those to likely fiscal space, to assess feasibility. Methods Public sector payroll data from 2015 from each country was used for the workforce analysis and does not include the private sector. Data were coded into the major cadres defined by the International Standard Classification of Occupations (ISCO-88). We estimated health worker training numbers and costs to meet international health worker density targets in the future and used sensitivity analysis to model hypothetical alternate estimates of attrition, drop-outs, and employment rates. Results Health worker-to-population density targets per 1000 population for doctors, nurses, and midwives are only specified in Liberia (1.12) and Guinea’s (0.78) investment plans and fall far short of the regional average for Africa (1.33) or international benchmarks of 2.5 per 1000 population and 4.45 for universal health coverage. Even these modest targets translate into substantial scaling-up requirements with Liberia having to almost double, Guinea quadruple, and Sierra Leone having to increase its workforce by seven to tenfold to achieve Liberia and Guinea’s targets. Costs per capita to meet the 2.5 per 1000 population density targets with 5% attrition, 10% drop-out, and 75% employment rate range from US$4.2 in Guinea to US$7.9 in Liberia in 2029, with projected fiscal space being adequate to accommodate the proposed scaling-up targets in both countries. Conclusions Achieving even a modest scale-up of health workforce will require a steady growth in health budgets, a long-term horizon and substantial scale-up of current training institution capacity. Increasing value-for-money in health workforce investments will require more efficient geographical distribution of the health workforce and more consideration to the mix of cadres to be scaled-up. Electronic supplementary material The online version of this article (10.1186/s12960-019-0351-y) contains supplementary material, which is available to authorized users.

COVID-19 Pandemic Readiness Status of West Africa

“…Overall, the main strengths of member states and the region for that matter include: in country capacity to test; strong political support; the existence of incident management systems (IMS) and rapid response teams (RRTs) that are on alert for activation, the availability of three tiers of skilled eld epidemiology workforce, the availability of experienced public health practitioners able to adopt existing and new preparedness and response protocols to country-speci c contexts; and their readiness to collaborate on cross-border surveillance and response. These strengths represent modest gains in health system resilience of the ECOWAS region as envisaged by WAHO and development partners following some investments in region (16)(17)(18).…”

‘Never let a crisis go to waste’: post-Ebola agenda-setting for health system strengthening in Guinea

“…Second, from a global health perspective, this financial support served to implement policies such as raising epidemic awareness which could reduce the perceived risk felt by Western citizens 36. McPake et al in their estimates of fiscal space projections in West African Ebola-affected countries report a declining projection (6%) of total health expenditures between 2020 and 2030 in Guinea 37. This suggests that policy actors in the MoH should develop strategies to overcome this situation which may impede the achievement or sustainability of the current GHS goals 37.…”

“…McPake et al in their estimates of fiscal space projections in West African Ebola-affected countries report a declining projection (6%) of total health expenditures between 2020 and 2030 in Guinea 37. This suggests that policy actors in the MoH should develop strategies to overcome this situation which may impede the achievement or sustainability of the current GHS goals 37. Therefore, they should prioritise efficiency management of HCWs by decentralising recruitment, removing ghost workers and communicating effectively on the outcomes of HSS on health indicators.…”

Expressions of psychological distress in Sierra Leone: implications for community-based prevention and response

“…universal mental health provision through a psychiatricallytrained cadre of health workers unfeasible to attain within the foreseeable future (Bah et al, 2018;McPake et al, 2019).…”

“…A roll-out of Psychological First Aid training for primary healthcare workers (Sijbrandij et al ., 2020) has lacked the follow-up that research has indicated is required to sustain a major uplift in capacity in this setting (Horn et al ., 2019). In combination, a lack of sustained funding and a severe shortage of healthcare personnel renders universal mental health provision through a psychiatrically-trained cadre of health workers unfeasible to attain within the foreseeable future (Bah et al ., 2018; McPake et al ., 2019).…”